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    v1.0.28
    OpenPayerPolicy UpdatesEndocrinologyCareOregon Growth Hormone Prior Auth | OpenPayer
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    DraftcareoregonPolicy N/A

    Growth Hormone Prior Authorization

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    Defines prior authorization requirements for branded growth hormone products for adult and pediatric members, including clinical criteria, prescriber requirements, product-step rationale, required documentation, and a 12-month approval length.

    Policy Summary
    Payercareoregon
    PolicyGrowth Hormone Prior Authorization
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateJul 1, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization with documentation of endocrinology involvement and required diagnostic evidence (stimulation test results or surgical/panhypopituitarism history); approvals are for 12 months.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 moapproval length
    21adult threshold
    <21pediatric threshold
    endocrinologistprescriber

    Coverage Criteria for Growth Hormone Therapy

    Policy Summary
    Payercareoregon
    PolicyGrowth Hormone Prior Authorization
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateJul 1, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization with documentation of endocrinology involvement and required diagnostic evidence (stimulation test results or surgical/panhypopituitarism history); approvals are for 12 months.
    SourceLink
    On This Page
    Coverage Criteria for Growth Hormone TherapyKey Clinical Thresholds and Coding NotesProvider Actions, Documentation, and Product SelectionBackground and ScopeDefinitions and Medical Necessity

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Initial Therapy (Adult)

    Covered when ALL of the following are met for members aged 21 years or older:

    Adult initial: Requested drug is FDA-approved for the condition being treated

    chunk 5

    Age: Member is 21 years of age or older

    chunk 5

    Prescriber: Prescribed by or in consultation with an endocrinologist

    chunk 5

    Anti-aging exclusion attestation: Prescriber certified that the growth hormone is not being prescribed for anti-aging therapy or to enhance athletic ability or bodybuilding

    chunk 5

    Deficiency evidence: One of the following: member had the pituitary removed or destroyed or has had panhypopituitarism since birth OR growth hormone deficiency confirmed by a negative response to a growth hormone stimulation test (e.g., stimulated serum GH < 5 ng/mL with glucagon or insulin)stimulated GH < 5 ng/mL

    chunk 5

    Product rationale: If the request is for Genotropin, Omnitrope, or Nutropin, provide rationale why Zomacton cannot be used; OR if the request is for Norditropin, provide rationale why Zomacton, Genotropin, Omnitrope, and Nutropin cannot be used

    chunks 5,7

    Reauthorization (Adult)

    Covered when ALL of the following are met for reauthorization:

    Reauthorization general: Requested drug is FDA-approved for the condition being treated

    chunk 5

    Documentation of response: Submission of medical records (e.g., chart notes) documenting response to growth hormone is required

    chunk 5

    Initial Therapy (Pediatric)

    Covered when ALL of the following are met for members under 21 years of age:

    Age: Member is under 21 years of age

    chunks 5,8

    FDA approval: Requested drug is FDA-approved for the condition being treated

    chunk 5

    Prescriber: Prescribed by or in consultation with an endocrinologist

    chunk 5

    State medical necessity: Request meets the definition of medical necessity per Oregon Administrative Rules

    chunk 5

    Reauthorization (Pediatric)

    Covered when ALL of the following are met for pediatric reauthorization:

    Age: Member is under 21 years of age

    chunk 8

    Continued medical necessity: Continuation of growth hormone is medically necessary

    chunk 8

    The prescriber must attest that the requested growth hormone is not being prescribed for anti-aging therapy or to enhance athletic ability or bodybuilding. This certification is a required element of approval for adult and pediatric requests.

    Requests that do not include required diagnostic confirmation will be considered not medically necessary. For adults this includes absence of documentation that the pituitary was removed or destroyed or evidence of panhypopituitarism since birth, or missing growth hormone stimulation test results showing a stimulated serum GH < 5 ng/mL. For all requests, lack of documentation of endocrinology involvement or missing medical records required for reauthorization (e.g., chart notes documenting response to therapy) may result in denial.

    Key Clinical Thresholds and Coding Notes

    Growth hormone stimulation test threshold
    Stimulated serum GH thresholdStimulated serum growth hormone less than 5 ng/mL on stimulation testing (e.g., with glucagon or insulin)
    Test types referencedGlucagon or insulin stimulation tests are acceptable methods for stimulation testing
    Context of useUsed to confirm growth hormone deficiency for adult initial authorization when pituitary removal/destruction or panhypopituitarism is not documented

    Provider Actions, Documentation, and Product Selection

    Prior Authorization

    Prior authorization required — 12-month approval

    Prior authorization is required for the listed growth hormone products; approvals (initial and reauthorization) are issued for a 12-month period.

    Step Therapy

    Provide product-specific rationale when requesting branded agents

    When requesting a specific branded product, the request must include a rationale explaining why preferred alternatives (notably Zomacton and, depending on the product requested, other listed brands) cannot be used.

    • If request is for Genotropin, Omnitrope, or Nutropin — provide rationale why Zomacton cannot be used.
    • If request is for Norditropin — provide rationale why Zomacton, Genotropin, Omnitrope, and Nutropin cannot be used.
    Documentation Required

    Submit medical records and baseline diagnostic documentation

    Submit medical records (for example, chart notes) documenting clinical response to growth hormone for reauthorization; for initial adult approval, include documentation of baseline testing or surgical/panhypopituitarism history as applicable.

    • Reauthorization: medical records/chart notes showing response to therapy.
    • Initial adult requests: stimulation test results (e.g., stimulated GH < 5 ng/mL) or documentation of pituitary removal/destruction or panhypopituitarism since birth.
    Denial Risk

    Denial triggers — missing age, prescriber, FDA-approval, or diagnostic proof

    Requests that do not document member age category, prescriber endocrinology involvement, FDA-approval for the indication, or required diagnostic confirmation (or surgical/panhypopituitarism history) are at risk of denial.

    • Member age not documented (adult ≥21 years or pediatric <21 years).
    • Prescriber is not an endocrinologist and no consultation documented.
    • Requested drug is not FDA‑approved for the condition being treated.
    • Missing diagnostic confirmation (no stimulation test results) or no documentation of pituitary removal/destruction or panhypopituitarism.

    Background and Scope

    This policy separates criteria by age: adults are members aged 21 years or older and pediatric members are those under 21 years. Adult initial approval requires prescribing by or in consultation with an endocrinologist and either surgical/destructive pituitary history or biochemical confirmation of growth hormone deficiency by stimulation testing (e.g., stimulated GH < 5 ng/mL). Pediatric requests likewise require endocrinology involvement and that the request meet the Oregon definition of medical necessity, demonstrating benefit toward age-appropriate growth, development, or function.

    Definitions and Medical Necessity

    Confirmed adult growth hormone deficiency
    Confirmed adult GHD definitionEither the pituitary was removed or destroyed, or the member has had panhypopituitarism since birth, or growth hormone deficiency is confirmed by a negative stimulation test
    Stimulation test criterionNegative response defined as stimulated serum GH < 5 ng/mL on glucagon or insulin stimulation testing
    Prescriber requirementPrescribed by or in consultation with an endocrinologist for adults
    Pediatric medical necessity
    Definition of medical necessity (pediatric)Treatment that prevents, diagnoses, or treats a disorder causing health impairment or disability; improves age-appropriate growth and development; or helps attain/maintain independence in self-care or activities of daily living as defined by Oregon Administrative Rules
    Age criterionApplies to members under 21 years of age
    Prescriber requirementPrescribed by or in consultation with an endocrinologist
    Functional benefit: Treatment aims to prevent, diagnose, or treat a disorder that results in health impairment or disability, improve age-appropriate growth and development, or establish/restore/maintain independence in self-care or activities of daily living

    chunk 6

    Product rationale: If the request is for Norditropin, provide rationale why Genotropin, Nutropin, and Omnitrope cannot be used

    chunk 7